For discussion and debate about the ethics of health care organizations and the wider health system.

Saturday, October 27, 2007

A Needed Speech about Health Care Rationing

The October “Election 2008” survey from the invaluable Kaiser Family Foundation election tracking project sent me to my file cabinet.

In January 1998 I spoke to the Vermont Leadership Institute about “Setting Limits: A Health Care System that Plays Fair.” I knew nothing about the Vermont Governor (Howard Dean) at the time, but part of my presentation was a speech I wished he would give. (I sent it to his office but nothing came of it.)

There is a tendency in the health policy community to believe that the U.S. is too individualistic to accept externally imposed health care limits, whether by Medicare or private insurers. This is why we are turning to “consumer directed health care” and the transfer of financial risk to the individual.

I can’t prove it, but my strong hunch has been that with leadership of the kind that John Kitzhaber provided as governor of Oregon we might not turn out to be so hopeless re understanding the need for health care limits and being able to accept limits set by a fair process.

Here is the speech I still believe needs to be given:

My fellow Vermonters. Four years ago your political leaders felt frustrated by our failure to achieve comprehensive health care reform. Now, with hindsight, we see that you, the public, were right to slow us down. The way the Clinton plan crashed and burned shows the wisdom of your counsel!

Part of the problem for health care reform is technical. Health policy is complicated. The dueling experts who advised us about the single payer system and the competitive model all made good arguments. But we Vermonters know you can “prove” almost any conclusion by packaging the numbers cleverly, so we ended up skeptical!

The deeper problem is values. Our nation has been confused about what it can reasonably expect from the health care system. If we ask the system to do anything that has the slightest possibility of extending life for the individual patient, no matter how costly and how uncertain, are we prepared to sacrifice other public goods to make this happen? If we ask the system to seek the greatest benefit for the population within the limits of a budget, can we accept the painful consequences this may entail for the individual patient?

Until we decide where we want the health care system to go, we can’t possibly reform the way in which we get there.

First, Vermonters are committed to continuing to provide insurance for the elderly and the poor. Support for Medicare and Medicaid is rock solid.

Second, we Vermonters are committed to finding a way to insure our 65,000 fellow citizens who are currently uninsured.

Finally, if rationing or other big changes have to happen, Vermonters want to be involved all along the way. No behind-closed-doors planning for us!

Today I want to launch us on the next step in health care reform. We know from states like Oregon and experience elsewhere in the world that providing excellent care to everyone will require us to set priorities. We Vermonters don’t mince words. That means rationing.

I have therefore asked the Commission on the Public’s Health Care Values and Priorities to help us identify the key values that should guide us in setting priorities and rationing. I have directed the Commission to learn from experience elsewhere as part of the process of public reflection, and to give us a full report 12 months from now, in January 1999.

If we can cooperate in addressing these challenging questions, Vermont will be able to start the new millennium with a meaningful package of health care reform that can address our unique circumstances and teach something to our brethren in the flatlands as well. Thank you and Godspeed!

About Me

I've been in health care for 50 years -- as psychiatrist, medical director, teacher/researcher, consultant, leader of the ethics program at a not-for-profit health plan, and patient. I'm a clinical professor in the departments of Population Medicine and Psychiatry at Harvard Medical School. With colleagues I've written two books about health system ethics: "Setting Limits Fairly: Learning to Share Resources for Health," and "No Margin, No Mission: Health-Care Organizations and the Quest for Ethical Excellence." I've had my Medicare card since 2004.

About the blog

Medical ethics has traditionally focused on the individual patient, the individual doctor, and the patient-doctor relationship. But today most care occurs in organizational settings – group practices, HMOs and ACOs, VA and more. Insurers and other third parties have a huge influence on the exam room. Medicare shapes care for the elderly and disabled. Medicaid does the same for the poor. Hospital cultures and policies affect what sick patients experience, for both better and worse.

All this means that the ethical quality of health care is profoundly influenced by the ethics of organizations. We can’t have ethical health care without ethical organizations.

In the blog I discuss how organizations engage with the ethical dimensions of their work. I look for approaches we can learn from, not simply to wring my hands and rant. I hope the blog stimulates discussion and debate, and encourage readers to present their own perspectives and suggest topics for postings. Although organizational ethics is my main focus, I also write about other ethical issues that interest me.